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Blake JM, Kohli U, Hallman KM, Shehata BM, Sriram CS. Clinico-histopathological correlation of symptomatic left main coronary artery electrocardiographic ischemia pattern in a young child with hypertrophic cardiomyopathy. J Electrocardiol 2021; 70:75-78. [PMID: 34971851 DOI: 10.1016/j.jelectrocard.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 10/19/2022]
Abstract
The specific electrocardiographic (ECG) pattern of left main coronary artery ischemia is exceptionally rare in children and under recognized. Occasional reports are bereft of a detailed mechanistic ECG description and limited to dissection, spasm, or anomalous origin of the left main coronary artery. An association with pediatric hypertrophic cardiomyopathy (HCM) is hitherto unreported. We furbish a detailed electrocardiographic description of this entity in the unusual setting of a 4-year-old child with HCM with a restrictive phenotype and exertional symptoms consistent with myocardial ischemia. Heart transplant was performed for this rare indication. Histopathology of the explanted heart in particular revealed left main coronary artery narrowing and provided us with a unique window of opportunity to correlate with clinical findings. The pathophysiology was also likely exacerbated by diffuse sub endocardial ischemia in the milieu of left ventricular hypertrophy with elevated end diastolic pressures. We anticipate that this illustrative case will help contextualize this as well as pediatric scenarios in which the 'left main ischemia' ECG pattern can be encountered and foster an accurate electrocardiographic recognition of this entity in children.
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Affiliation(s)
- Jennifer M Blake
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Utkarsh Kohli
- Division of Pediatric Cardiology, Department of Pediatrics, West Virginia University Children's Hospital and West Virginia University School of Medicine, Morgantown, WV, USA
| | | | - Bahig M Shehata
- Division of Pathology, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Chenni S Sriram
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA.
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2
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Madias JE. Apparent electrocardiogram left ventricular hypertrophy during tachycardia. J Electrocardiol 2021; 65:3-7. [PMID: 33460860 DOI: 10.1016/j.jelectrocard.2021.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/31/2020] [Accepted: 01/06/2021] [Indexed: 12/16/2022]
Abstract
The electrocardiographic transient display of left ventricular hypertrophy (LVH), during rapid heart rates, in the setting of sinus/supraventricular tachycardias and atrial fibrillation, is illustrated via 3 case reports. This common occurrence is expressed by an increase in the S-waves in leads V2-V5, during tachycardias, rendering a false positive diagnosis of LVH by the frequently employed Cornell voltage LVH criteria. This tachycardia-mediated apparent LVH, is unrelated to the occasionally encountered stable, and unrelated to tachycardia, "false positive diagnosis of LVH", which could in reality occasionally reflect altered electrical properties of myocardium that could create a functional substrate for developing arrhythmias. The importance of awareness of this insight by all health professionals is immeasurable, considering that a false positive diagnosis of LVH has major consequences in the management, prognostication, resort to expensive unnecessary testing, and stress to the patients and their families.
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Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America; Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United States of America.
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3
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Bacharova L. Reciprocal ST segment depressions in myocardial infarction which are not reciprocal. J Electrocardiol 2020; 61:61-62. [DOI: 10.1016/j.jelectrocard.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 05/24/2020] [Accepted: 05/30/2020] [Indexed: 10/24/2022]
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4
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Ter Haar CC, Kors JA, Peters RJG, Tanck MWT, Snijder MB, Maan AC, Swenne CA, van den Born BJH, de Jong JSSG, Macfarlane PW, Postema PG. Prevalence of ECGs Exceeding Thresholds for ST-Segment-Elevation Myocardial Infarction in Apparently Healthy Individuals: The Role of Ethnicity. J Am Heart Assoc 2020; 9:e015477. [PMID: 32573319 PMCID: PMC7670498 DOI: 10.1161/jaha.119.015477] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background Early prehospital recognition of critical conditions such as ST‐segment–elevation myocardial infarction (STEMI) has prognostic relevance. Current international electrocardiographic STEMI thresholds are predominantly based on individuals of Western European descent. However, because of ethnic electrocardiographic variability both in health and disease, there is a need to reevaluate diagnostic ST‐segment elevation thresholds for different populations. We hypothesized that fulfillment of ST‐segment elevation thresholds of STEMI criteria (STE‐ECGs) in apparently healthy individuals is ethnicity dependent. Methods and Results HELIUS (Healthy Life in an Urban Setting) is a multiethnic cohort study including 10 783 apparently healthy subjects of 6 different ethnicities (African Surinamese, Dutch, Ghanaian, Moroccan, South Asian Surinamese, and Turkish). Prevalence of STE‐ECGs across ethnicities, sexes, and age groups was assessed with respect to the 2 international STEMI thresholds: sex and age specific versus sex specific. Mean prevalence of STE‐ECGs was 2.8% to 3.4% (age/sex‐specific and sex‐specific thresholds, respectively), although with large ethnicity‐dependent variability. Prevalences in Western European Dutch were 2.3% to 3.0%, but excessively higher in young (<40 years) Ghanaian males (21.7%–27.5%) and lowest in older (≥40 years) Turkish females (0.0%). Ethnicity (sub‐Saharan African origin) and other variables (eg, younger age, male sex, high QRS voltages, or anterolateral early repolarization pattern) were positively associated with STE‐ECG occurrence, resulting in subgroups with >45% STE‐ECGs. Conclusions The accuracy of diagnostic tests partly relies on background prevalence in healthy individuals. In apparently healthy subjects, there is a highly variable ethnicity‐dependent prevalence of ECGs with ST‐segment elevations exceeding STEMI thresholds. This has potential consequences for STEMI evaluations in individuals who are not of Western European descent, putatively resulting in adverse outcomes with both over‐ and underdiagnosis of STEMI.
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Affiliation(s)
- C Cato Ter Haar
- Department of Cardiology Heart Center Amsterdam UMC University of Amsterdam The Netherlands.,Department of Cardiology Heart-Lung Center Leiden University Medical Center Leiden The Netherlands
| | - Jan A Kors
- Department of Medical Informatics Erasmus MC University Medical Center Rotterdam The Netherlands
| | - Ron J G Peters
- Department of Cardiology Heart Center Amsterdam UMC University of Amsterdam The Netherlands
| | - Michael W T Tanck
- Department of Clinical Epidemiology Biostatistics & Bioinformatics, Amsterdam Public Health Research Institute Amsterdam UMC University of Amsterdam The Netherlands
| | - Marieke B Snijder
- Department of Clinical Epidemiology Biostatistics & Bioinformatics, Amsterdam Public Health Research Institute Amsterdam UMC University of Amsterdam The Netherlands.,Department of Public Health Amsterdam Public Health research institute Amsterdam UMC University of Amsterdam The Netherlands
| | - Arie C Maan
- Department of Cardiology Heart-Lung Center Leiden University Medical Center Leiden The Netherlands
| | - Cees A Swenne
- Department of Cardiology Heart-Lung Center Leiden University Medical Center Leiden The Netherlands
| | - Bert-Jan H van den Born
- Department of Vascular Medicine Amsterdam UMC University of Amsterdam Amsterdam the Netherlands
| | | | | | - Pieter G Postema
- Department of Cardiology Heart Center Amsterdam UMC University of Amsterdam The Netherlands
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5
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Haar CC, Peters RJG, Bosch J, Sbrollini A, Gripenstedt S, Adams R, Bleijenberg E, Kirchhof CJHJ, Alizadeh Dehnavi R, Burattini L, Winter RJ, Macfarlane PW, Postema PG, Man S, Scherptong RWC, Schalij MJ, Maan AC, Swenne CA. An initial exploration of subtraction electrocardiography to detect myocardial ischemia in the prehospital setting. Ann Noninvasive Electrocardiol 2020; 25:e12722. [PMID: 31707764 PMCID: PMC7358788 DOI: 10.1111/anec.12722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 09/16/2019] [Accepted: 10/02/2019] [Indexed: 11/28/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Cornelia Cato Haar
- Department of Cardiology Heart Center Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
- Department of Cardiology Heart‐Lung Center Leiden University Medical Center Leiden The Netherlands
| | - Ron J. G. Peters
- Department of Cardiology Heart Center Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Jan Bosch
- Department of R&D Regionale Ambulancevoorziening Hollands Midden Leiden The Netherlands
| | - Agnese Sbrollini
- Department of Information Engineering Università Politecnica delle Marche Ancona Italy
| | - Sophia Gripenstedt
- Department of Cardiology Heart Center Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Rob Adams
- Department of Cardiology Heart Center Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | | | | | - Reza Alizadeh Dehnavi
- Department of Cardiology Heart‐Lung Center Leiden University Medical Center Leiden The Netherlands
- Cardiology Department Groene Hart Hospital Gouda The Netherlands
| | - Laura Burattini
- Department of Information Engineering Università Politecnica delle Marche Ancona Italy
| | - Robbert J. Winter
- Department of Cardiology Heart Center Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | | | - Pieter G. Postema
- Department of Cardiology Heart Center Amsterdam UMC University of Amsterdam Amsterdam The Netherlands
| | - Sumche Man
- Department of Cardiology Heart‐Lung Center Leiden University Medical Center Leiden The Netherlands
| | | | - Martin J. Schalij
- Department of Cardiology Heart‐Lung Center Leiden University Medical Center Leiden The Netherlands
| | - Arie C. Maan
- Department of Cardiology Heart‐Lung Center Leiden University Medical Center Leiden The Netherlands
| | - Cees A. Swenne
- Department of Cardiology Heart‐Lung Center Leiden University Medical Center Leiden The Netherlands
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Correlation between septal midwall late gadolinium enhancement on CMR and conduction delay on ECG in patients with nonischemic dilated cardiomyopathy. IJC HEART & VASCULATURE 2020; 26:100474. [PMID: 32021905 PMCID: PMC6994302 DOI: 10.1016/j.ijcha.2020.100474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 12/20/2022]
Abstract
Background Septal midwall late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) is a characteristic finding in nonischemic dilated cardiomyopathy (DCM) and is associated with adverse cardiac events. QRS-prolongation in DCM is also frequently present and a predictor of arrhythmic events and mortality. Since the His-Purkinje fibres are located in the interventricular septum, QRS-prolongation may directly result from septal fibrosis, visualized by LGE. Our aim was to study the correlation of the presence and extent of septal midwall LGE and QRS-duration. Methods DCM-patients with left ventricular (LV) dysfunction (LVEF < 50%) were included. LV volumes, systolic function and nonischemic septal midwall LGE, defined as patchy or stripe-like LGE in the septal segments, were quantified. QRS-duration on standard 12-lead ECG was measured. Results 165 DCM-patients were included (62% male, mean age 59 ± 15 years) with a median LVEF of 36% [24–44]. Fifty-one patients (31%) demonstrated septal midwall LGE with a median extent of 8.1 gram [4.3–16.8]. Patients with midwall LGE had increased LV end-diastolic volumes (EDV) 248 mL [193–301] vs. 193 mL [160–239], p < 0.001) and lower LVEF (26% [18–35] vs. 40% [32–45], p < 0.001). Median QRS-duration was 110 ms [95–146] without a correlation to the presence nor extent of midwall LGE. QRS-duration was moderately correlated with LV-dilation and mass (respectively r = 0.35, p < 0.001 and r = 0.30, p < 0.001). Conclusion In DCM-patients, QRS-prolongation and septal midwall LGE are frequently present and often co-exist. However, they are not correlated. This suggests that the assessment of LGE-CMR has complementary value to ECG evaluation in the clinical assessment and risk stratification of DCM-patients.
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Evaluation of the Tp-e interval and Tp-e/QTc ratio in patients with benign paroxysmal positional vertigo in the emergency department compared with the normal population. J Electrocardiol 2020; 58:51-55. [DOI: 10.1016/j.jelectrocard.2019.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 10/15/2019] [Accepted: 11/01/2019] [Indexed: 01/08/2023]
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8
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Tolppanen H, Javanainen T, Sans-Rosello J, Parenica J, Nieminen T, Pavlusova M, Masip J, Köber L, Banaszewski M, Sionis A, Spinar J, Harjola VP, Jurkko R, Lassus J. Prevalence, Temporal Evolution, and Impact on Survival of Ventricular Conduction Blocks in Patients With Acute Coronary Syndrome and Cardiogenic Shock. Am J Cardiol 2018; 122:199-205. [PMID: 29778237 DOI: 10.1016/j.amjcard.2018.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/24/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
Abstract
Changes in QRS duration and pattern are regarded to reflect severe ischemia in acute coronary syndromes (ACS), and ventricular conduction blocks (VCBs) are recognized high-risk markers in both ACS and acute heart failure. Our aim was to evaluate the prevalence, temporal evolution, association with clinical and angiographic parameters, and impact on mortality of VCBs in ACS-related cardiogenic shock (CS). Data of 199 patients with ACS-related CS from a prospective multinational cohort were evaluated with electrocardiogram data from baseline and day 3. VCBs including left or right bundle branch block, right bundle branch block and hemiblock, isolated hemiblocks, and unspecified intraventricular conduction delay were assessed. Fifty percent of patients had a VCB at baseline; these patients were older, had poorer left ventricular function and had more often left main disease compared with those without VCB. One-year mortality was over 2-fold in patients with VCB compared with those without VCB (68% vs 32%, p<0.001). All types of VCBs at baseline were associated with increased mortality, and the predictive value of a VCB was independent of baseline variables and coronary angiography findings. Interestingly, 37% of the VCBs were transient, i.e., disappeared before day 3. However, 1-year mortality was much higher in these patients (69%) compared to patients with persistent (38%) or no VCB (15%, p<0.001). Indeed, a transient VCB was a strong independent predictor of 1-year mortality. In conclusion, our findings propose that any VCB in baseline electrocardiogram, even if transient, identifies very early patients at particularly high mortality risk in ACS-related CS.
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Dr. Galen Wagner (1939-2016) as an Academic Writer: An Overview of his Peer-reviewed Scientific Publications. J Electrocardiol 2017; 50:47-73. [DOI: 10.1016/j.jelectrocard.2016.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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10
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Bacharova L, Estes HE, Schocken DD, Ugander M, Soliman EZ, Hill JA, Bang LE, Schlegel TT. The 4th Report of the Working Group on ECG diagnosis of Left Ventricular Hypertrophy. J Electrocardiol 2016; 50:11-15. [PMID: 27890283 DOI: 10.1016/j.jelectrocard.2016.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Indexed: 12/18/2022]
Abstract
The 4th Report provides a brief review of publications focused on the electrocardiographic diagnosis of left ventricular hypertrophy published during the period of 2010 to 2016 by the members of the Working Group on ECG diagnosis of Left Ventricular Hypertrophy. The Working Group recommended that ECG research and clinical attention be redirected from the estimation of LVM to the identification of electrical remodeling, to better understanding the sequence of events connecting electrical remodeling to outcomes. The need for a re-definition of terms and for a new paradigm is also stressed.
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Affiliation(s)
- Ljuba Bacharova
- International Laser Center, Bratislava, Slovak Republic; Institute of Pathophysiology, Medical School, Comenius University, Bratislava, Slovak Republic.
| | - Harvey E Estes
- Department of Community and Family Medicine, Duke University Medical Center, Durham, NC, USA
| | | | - Martin Ugander
- Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center (EPICARE), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Joseph A Hill
- Department of Internal Medicine, Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lia E Bang
- Copenhagen University Hospital, Rigshospitalet, The Heart Center, Department of Cardiology, Denmark
| | - Todd T Schlegel
- Department of Clinical Physiology, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden; Nicollier-Schlegel SARL, Trélex, Switzerland
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Romero D, Martínez JP, Laguna P, Pueyo E. Ischemia detection from morphological QRS angle changes. Physiol Meas 2016; 37:1004-23. [DOI: 10.1088/0967-3334/37/7/1004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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12
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Demidova MM, Martín-Yebra A, Koul S, Engblom H, Martínez JP, Erlinge D, Platonov PG. QRS broadening due to terminal distortion is associated with the size of myocardial injury in experimental myocardial infarction. J Electrocardiol 2016; 49:300-6. [DOI: 10.1016/j.jelectrocard.2016.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Indexed: 11/27/2022]
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Yochai B, Nikus K, Birnbaum Y. About QRS prolongation, distortion and the acuteness score. J Electrocardiol 2016; 49:265-71. [PMID: 26972846 DOI: 10.1016/j.jelectrocard.2016.02.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Indexed: 01/25/2023]
Affiliation(s)
- Birnbaum Yochai
- The Section of Cardiology, the Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kjell Nikus
- Cardiology Department, Heart Center, Tampere University Hospital and School of Medicine, University of Tampere, Finland
| | - Yochai Birnbaum
- The Section of Cardiology, the Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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Almer J, Jennings RB, Maan AC, Ringborn M, Maynard C, Pahlm O, Arheden H, Wagner GS, Engblom H. Ischemic QRS prolongation as a biomarker of severe myocardial ischemia. J Electrocardiol 2016; 49:139-47. [DOI: 10.1016/j.jelectrocard.2015.12.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Indexed: 10/22/2022]
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Carlsen EA, Bang LE, Køber L, Strauss DG, Amaral M, Barbagelata A, Warren S, Wagner GS. Availability of a baseline Electrocardiogram changes the application of the Sclarovsky-Birnbaum Myocardial Ischemia Grade. J Electrocardiol 2014; 47:571-6. [DOI: 10.1016/j.jelectrocard.2014.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Indexed: 12/01/2022]
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Gomis P, Caminal P. Evaluation of very low amplitude intra-QRS potentials during the initial minutes of acute transmural myocardial ischemia. J Electrocardiol 2014; 47:512-9. [DOI: 10.1016/j.jelectrocard.2014.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Indexed: 10/25/2022]
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Bonomini MP, Corizzo SJ, Laguna P, Arini PD. 2D ECG differences in frontal vs preferential planes inpatients referred for percutaneous transluminal coronary angioplasty. Biomed Signal Process Control 2014. [DOI: 10.1016/j.bspc.2014.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
Shortly following an occlusion of an epicardial coronary artery, changes in the surface electrocardiogram (ECG) can be detected. Initially, T waves in leads with their positive poles facing the ischemic zone become positive, tall and symmetrical. Later, ST segment elevation (STE) becomes apparent. If ischemia continues, changes in the terminal portion of the QRS may also be detected. The changes in the terminal portion of the QRS are believed to be caused by prolongation of the electrical conduction in the ischemic zone and reflect severe ischemia due to lack of protection by preconditioning or collateral circulation. Several groups have shown that patients with the QRS changes of grade 3 ischemia have higher mortality, higher incidence of reinfarction and heart failure than patients presenting with only the T and ST changes of grade 2 ischemia, despite equal success in recanalizing the epicardial coronary artery by either thrombolytic therapy or primary percutaneous coronary intervention. Grade 3 ischemia is associated with more rapid progression of necrosis and larger final infarct size. Further studies are needed to better understand the underlying mechanisms that determine the severity of ischemia and how we should use this method based on the standard 12 lead ECG to implement clinical therapeutic decisions.
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QRS complex and ST segment manifestations of ventricular ischemia: The effect of regional slowing of ventricular activation. J Electrocardiol 2013; 46:497-504. [DOI: 10.1016/j.jelectrocard.2013.08.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Indexed: 11/22/2022]
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20
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Niu T, Fu P, Jia C, Dong Y, Liang C, Cao Q, Yang Z, Fu R, Zhang X, Sun Z. The delayed activation wave in non-ST-elevation myocardial infarction. Int J Cardiol 2013; 162:107-11. [PMID: 21663984 DOI: 10.1016/j.ijcard.2011.05.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Revised: 03/01/2011] [Accepted: 05/13/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND Little is known about the relationship between the electrocardiographic characteristics and the infarct related artery (IRA) in non-ST-elevation myocardial infarction (NSTEMI). We found a curious phenomenon in electrocardiograms of patients with acute occlusion of left circumflex artery in NSTEM: A notch or deflection was often present in the terminal QRS complex in leads II,III and aVF or I,aVL . The objective of this study was to determine whether the previously unreported ECG phenomenon that we have found in NSTEMI could identify the culprit artery in non-ST-elevation myocardial infarction. METHODS AND RESULTS Our study included 218 NSTEMI patients who presented to our institution and underwent coronary angiography within 24 hours of admission. For convenience, 'N' wave was defined as a notch or deflection in the terminal QRS complex of the surface ECG. The duration of QRS with N wave before PCI was more prolonged than the duration of QRS without N wave (121 ± 12 ms vs 106 ± 11 ms, P<0.01). In the LCX group, 66(77%) patients had N wave in leads II, III and aVF, whereas only 5(6%) patients in the LAD group and 9(18%) patients in the RCA group had such ECG feature (P<0.001). A greater proportion of patients in the LCX group also had N waves in leads I and aVL (P<0.001). N wave in leads II, III and aVF was associated with 77% sensitivity and 89% specificity, respectively. N wave in leads I and aVL was associated with 64% sensitivity and 96% specificity, respectively. CONCLUSION The abnormal waveform in terminal QRS complex in NSTEMI ,which is described above, is the delayed activation wave of left ventricular basal region which the left circumflex artery supplies. It is associated with a higher specificity and higher sensitivity for culprit LCX in non-ST-elevation myocardial infarction. The delayed activation wave is a new pattern of ischemia in ECG.
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Affiliation(s)
- Tiesheng Niu
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang 110004, China.
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Ilkay E, Kacmaz F, Maden O, Aksu T, Selcuk MT, Erbay AR, Demir AD. A new electrocardiographic marker of myocardial reperfusion in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous intervention: the value of QRS duration. EUROINTERVENTION 2012; 7:1406-12. [PMID: 22522551 DOI: 10.4244/eijv7i12a220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Although ischaemia-induced QRS complex changes have been described previously, their relation with reperfusion status is not clear. We aimed to investigate the relation of QRS duration with reperfusion at tissue level compared to myocardial blush in patients with acute myocardial infarction who underwent successful primary percutaneous coronary angioplasty. METHODS AND RESULTS One hundred and forty-eight patients were enrolled. Based on the post-angioplasty myocardial blush grade (MBG), patients were divided into reperfusion (grades 2 and 3) and impaired reperfusion (grades 0 and 1) groups. Although the two groups did not differ in terms of admission QRS duration (81±17 vs. 79±15 msec, p=0.473), the patients in the impaired reperfusion group had a significantly longer QRS duration both at immediate post-angioplasty (78±18 vs. 68±17 msec, p=0.001) and at the 60th minute ECG (77±17 vs. 60±17 msec, p<0.001). Patients in the impaired reperfusion group revealed significantly less narrowing of QRS duration in the post-angioplasty 60th minute ECG (6±5 vs. 20±5 msec, p<0.001) when compared to the patients in the reperfusion group. After adjusting all variables, QRS narrowing in the 60th minute ECG was determined as an independent electrocardiographic predictor of reperfusion (OR:1.39, 95% CI: 1.25-1.54, p<0.001). CONCLUSIONS We demonstrated that QRS duration is a strong indicator of myocardial reperfusion status.
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Affiliation(s)
- Erdogan Ilkay
- Department of Cardiology, TOBB ETÜ Hospital, Ankara, Turkey
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Nimura A, Sakamoto N, Nakagawa N, Ota H, Tanabe Y, Takeuchi T, Natori S, Sato N, Hasebe N, Kawamura Y. Site of Transmural Late Gadolinium Enhancement on the Cardiac MRI Coincides With the ECG Leads Exhibiting Terminal QRS Distortion in Patients With ST-Elevation Myocardial Infarctions. Int Heart J 2012; 53:270-5. [DOI: 10.1536/ihj.53.270] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Asami Nimura
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University
| | - Naka Sakamoto
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University
| | - Naoki Nakagawa
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University
| | - Hisanobu Ota
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University
| | - Yasuko Tanabe
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University
| | - Toshiharu Takeuchi
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University
| | | | - Nobuyuki Sato
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University
| | - Naoyuki Hasebe
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University
| | - Yuichiro Kawamura
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University
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Evaluation of depolarization changes during acute myocardial ischemia by analysis of QRS slopes. J Electrocardiol 2011; 44:416-24. [DOI: 10.1016/j.jelectrocard.2011.03.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Indexed: 11/23/2022]
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Romero D, Ringborn M, Laguna P, Pahlm O, Pueyo E. Depolarization Changes During Acute Myocardial Ischemia by Evaluation of QRS Slopes: Standard Lead and Vectorial Approach. IEEE Trans Biomed Eng 2011; 58:110-20. [DOI: 10.1109/tbme.2010.2076385] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Correa R, Laciar E, Arini P, Jane R. Analysis of QRS loop changes in the beat-to-beat Vectocardiogram of ischemic patients undergoing PTCA. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2010; 2009:1750-3. [PMID: 19963763 DOI: 10.1109/iembs.2009.5333093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In the present work, we have studied dynamic changes of QRS loop in the Vectocardiogram (VCG) of 80 patients that underwent Percutaneous Transluminal Coronary Angioplasty (PTCA). The VCG was obtained for each patient using the XYZ orthogonal leads of their electrocardiographic (ECG) records acquired before, during and after PTCA procedure. In order to analyze the variations of VCG, it has been proposed in this study the following parameters a) Maximum module of the cardiac depolarization vector, b) Volume, c) and Area of vectocardiographic loop corresponding to the QRS complex of each beat, d) Maximum distance between Centroid and the Loop, e) Angle between the XY plane and the Optimum Plane, f) Relation between the Area and Perimeter. The results obtained indicate that the parameters proposed show significant statistics differences (p-value<0.05) before, during (with some exceptions at the first minute of balloon inflation) and after PTCA. We conclude that the variations observed in the proposed parameters correctly represent not only the morphological changes in the depolarization VCG but also they reflect the modifications in the levels of cardiac ischemia induced by PTCA.
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Affiliation(s)
- Raul Correa
- Gabinete de Tecnología Médica, Facultad de Ingeniería, Universidad Nacional. de San Juan, Argentina.
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26
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Nikus K, Pahlm O, Wagner G, Birnbaum Y, Cinca J, Clemmensen P, Eskola M, Fiol M, Goldwasser D, Gorgels A, Sclarovsky S, Stern S, Wellens H, Zareba W, de Luna AB. Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology. J Electrocardiol 2010; 43:91-103. [DOI: 10.1016/j.jelectrocard.2009.07.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2008] [Indexed: 10/20/2022]
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27
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Ringborn M, Pettersson J, Persson E, Warren SG, Platonov P, Pahlm O, Wagner GS. Comparison of high-frequency QRS components and ST-segment elevation to detect and quantify acute myocardial ischemia. J Electrocardiol 2010; 43:113-20. [DOI: 10.1016/j.jelectrocard.2009.11.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Indexed: 11/28/2022]
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28
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Chua SK, Shyu KG, Cheng JJ, Liou JY, Lin SC, Hung HF, Lee SH, Chiu CZ, Lo HM. Significance of left circumflex artery-related acute myocardial infarction without ST-T changes. Am J Emerg Med 2010; 28:183-8. [DOI: 10.1016/j.ajem.2008.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 10/06/2008] [Accepted: 11/07/2008] [Indexed: 10/19/2022] Open
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29
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Nakamura N, Gohda M, Satani O, Tomobuchi Y, Ueno Y, Tanimoto T, Kitabata H, Takarada S, Kubo T, Mizukoshi M, Hirata K, Tanaka A, Imanishi T, Akasaka T. Myocardial salvage for ST-elevation myocardial infarction with terminal QRS distortion and restoration of brisk epicardial coronary flow. Heart Vessels 2009; 24:96-102. [PMID: 19337792 DOI: 10.1007/s00380-008-1092-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Accepted: 07/10/2008] [Indexed: 11/30/2022]
Abstract
Recently, it has been reported that large infarcts associated with terminal QRS distortion (QRSDIS) on the admission electrocardiograms of patients with ST-elevation myocardial infarctions (STEMIs) may be caused by a failure to achieve thrombolysis in myocardial infarction (TIMI) grade 3 flow after primary percutaneous coronary intervention (PCI). However, the relationship between QRSDIS and final infarct size when TIMI grade 3 flow could be achieved by primary PCI is still unclear. Sixty-two consecutive patients with first anterior STEMI and who achieved TIMI grade 3 flow by primary PCI were classified into two groups according to the presence (Group A, n = 18) or absence (Group B, n = 44) of QRSDIS. Two weeks after the onset of acute myocardial infarction, Group A had a larger left ventricular (LV) end-systolic volume index (LVESVI) and a lower LV ejection fraction (LVEF) than Group B (LVESVI: 38 +/- 13 vs 31 +/- 12 ml/m(2), P = 0.025: LVEF: 42% +/- 10% vs 51% +/- 10%, P = 0.004). Through multivariate analysis, independent predictors of poor LV systolic function (LVEF < 40%) were determined to be the presence of QRSDIS (odds ratio 21.04, P = 0.021) and proximal left anterior descending artery occlusion (odds ratio 16.15, P = 0.033). Myocardial damage could not be reduced in patients experiencing STEMI with QRSDIS, even when TIMI grade 3 flow could be achieved by primary PCI, as much as in patients experiencing STEMI without QRSDIS.
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Affiliation(s)
- Nobuo Nakamura
- Department of Cardiovascular Medicine, Wakayama Medical University, Kimiidera, Wakayama, Japan
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Surawicz B, Childers R, Deal BJ, Gettes LS. AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram. J Am Coll Cardiol 2009; 53:976-81. [DOI: 10.1016/j.jacc.2008.12.013] [Citation(s) in RCA: 451] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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31
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Surawicz B, Childers R, Deal BJ, Gettes LS, Bailey JJ, Gorgels A, Hancock EW, Josephson M, Kligfield P, Kors JA, Macfarlane P, Mason JW, Mirvis DM, Okin P, Pahlm O, Rautaharju PM, van Herpen G, Wagner GS, Wellens H. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation 2009; 119:e235-40. [PMID: 19228822 DOI: 10.1161/circulationaha.108.191095] [Citation(s) in RCA: 266] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Celik T, Yuksel UC, Iyisoy A, Kilic S, Kardesoglu E, Bugan B, Isik E. The impact of preinfarction angina on electrocardiographic ischemia grades in patients with acute myocardial infarction treated with primary percutaneous coronary intervention. Ann Noninvasive Electrocardiol 2008; 13:278-86. [PMID: 18713329 DOI: 10.1111/j.1542-474x.2008.00232.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Grade 3 ischemia (G3I) is defined as ST elevation with distortion of the terminal portion of the QRS (emergence of the J point > 50% of the R wave in leads with qR configuration, or disappearance of the S wave in leads with an Rs configuration). Patients with G3I on the presenting electrocardiogram (ECG) had worse prognosis than the patients with lesser (grade 2-G2I) ischemia. The aim of this study is to examine the effects of preinfarct angina (PIA) on electrocardiographic ischemia grades. METHODS One hundred forty-eight consecutive patients with ST-segment myocardial infarction (STEMI) were included in this study. All patients underwent primary percutaneous coronary intervention. The admission ECGs was analyzed retrospectively for electrocardiographic ischemia grades and compared with the presence of PIA. RESULTS Study population consisted of 110 patients with G2I (88 men, mean age = 63 +/- 6 years) and 38 patients with G3I (32 men, mean age = 61 +/- 8 years). Baseline characteristics of the groups were the same except for patients with G3I had significantly longer pain to balloon time and higher admission creatine kinase MB isoenzyme (CK-MB) levels. Tissue myocardial perfusion grade (TMPG) was better in patients with G2I. While 18 patients (47%) with G3I had PIA, 81 patients (70%) with G2I had PIA (P = 0.005). Although pain to balloon time and admission CK-MB were independent predictor of worse electrocardiographic ischemia grade (OR 1.69, 95% CI 1.09-2.62; P = 0.01; OR 1.01, 1.00-1.02, P = 0.04), PIA and left ventricular ejection time (LVEF) were independent predictors of better electrocardiographic ischemia grade (OR 0.4, 95% CI 0.17-0.90; P = 0.02, OR 0.92, 95% CI 0.85-0.99; P = 0.03, respectively) in multivariate logistic regression analysis. CONCLUSION PIA is one of the most important clinical predictors of better ischemia grades especially when combined with the pain to balloon time, LVEF, and admission CK-MB levels in patients with STEMI. This study provided another evidence for the protective effects of PIA.
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Affiliation(s)
- Turgay Celik
- Gulhane Military Medical Academy, School of Medicine, Department of Cardiology, Etlik, Ankara, Turkey.
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Early electrocardiographic diagnosis of acute coronary ischemia on the paced electrocardiogram. Int J Cardiol 2008; 130:14-8. [DOI: 10.1016/j.ijcard.2007.07.136] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Revised: 07/02/2007] [Accepted: 07/07/2007] [Indexed: 11/22/2022]
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Pueyo E, Sornmo L, Laguna P. QRS Slopes for Detection and Characterization of Myocardial Ischemia. IEEE Trans Biomed Eng 2008; 55:468-77. [DOI: 10.1109/tbme.2007.902228] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Williams JL, Mendenhall GS, Saba S. Effect of ischemia on implantable defibrillator intracardiac shock electrograms. J Cardiovasc Electrophysiol 2007; 19:275-81. [PMID: 18081761 DOI: 10.1111/j.1540-8167.2007.01042.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Few attempts have been made to extract information from the ventricular electrogram (EGM) recorded by implantable cardioverter defibrillators (ICD) aside from the discrimination of supraventricular tachycardia and ventricular tachycardia. The current study aims to examine the effect of ischemia in the major coronary artery distributions on the shock EGM from ICDs. METHODS Domestic crossbred pigs (n = 10, 20-40 kg) were implanted with a dual-coil right ventricular defibrillation system. Through the femoral approach, percutaneous balloon occlusion of the major coronary arteries was performed. The left anterior descending (LAD), left circumflex (LCx), and right coronary (RCA) arteries were occluded in random order for 3-5 minutes with 30-minute periods of reperfusion in between and the shock EGMs were recorded and analyzed. RESULTS During peak ischemia, R wave amplitude increased by a mean of 204.3% (P = 0.003), increased by a mean of 73.8% (P = 0.0009), and decreased by a mean of 28.0% (P = 0.109) in the LAD, LCx, and RCA territories, respectively. During peak ischemia ST segments elevated by a mean of 105.3% (P = 0.041), elevated by a mean of 114.9% (P = 0.064), and decreased by a mean of 584.5% (P = 0.006) in the LAD, LCx, and RCA territories, respectively. CONCLUSIONS Ischemia affects ICD shock EGMs in a manner that appears to vary depending on the culprit vessel. Our data demonstrate the feasibility of ischemia detection from ICD shock EGMs.
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Affiliation(s)
- Jeffrey L Williams
- Cardiovascular Institute of the University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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36
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Maden O, Kaçmaz F, Selçuk MT, Selçuk H, Alyan O, Aksu T, Metin F, Tüfekçioğlu O, Atak R, Demir AD, Balbay Y, Ilkay E. Relation of admission QRS duration with development of angiographic no-reflow in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous interventions. J Electrocardiol 2007; 41:72-7. [PMID: 17888941 DOI: 10.1016/j.jelectrocard.2007.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Although QRS-complex changes during ischemia have been described previously, their relation with no-reflow is not clear. PURPOSE To evaluate relation of admission QRS duration with angiographic no-reflow, we studied 162 patients who underwent primary angioplasty. METHODS Twelve-lead electrocardiogram with a paper speed of 50 mm/s was recorded on admission and repeated after angioplasty. Patients were divided into reflow and no-reflow groups based on postangioplasty coronary thrombolysis in myocardial infarction flow grade. RESULTS Patients in the no-reflow group (26 patients) were older (P = .001) and had significantly longer pain-to-balloon interval (P = .007). The patients in the no-reflow group had significantly longer QRS duration on admission electrocardiogram compared with patients in the reflow group (interquartile range, 80-93 [median, 84] milliseconds vs 60-80 [median, 76] milliseconds, respectively; P < .001). After adjusting all variables, QRS duration on admission was found to be independently related to angiographic no-reflow (odds ratio, 1.07; 95% confidence interval, 1.02-1.12; P = .003). CONCLUSION QRS duration on admission may be valuable in predicting no-reflow.
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Affiliation(s)
- Orhan Maden
- Cardiology Department, Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey.
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Weston P, Johanson P, Schwartz LM, Maynard C, Jennings RB, Wagner GS. The value of both ST-segment and QRS complex changes during acute coronary occlusion for prediction of reperfusion-induced myocardial salvage in a canine model. J Electrocardiol 2006; 40:18-25. [PMID: 17069840 DOI: 10.1016/j.jelectrocard.2006.09.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Analysis of ST-segment elevation for assessment of patients with suspected acute coronary occlusion is in widespread use for diagnostic and prognostic purposes. In this study, changes in the QRS complex also were analyzed to determine if these changes that are seldom used clinically can provide additional prognostic information. An acute coronary occlusion canine model, in which direct measurements of myocardial salvage were made, was used to assess whether ST-segment and QRS complex changes during coronary occlusion yielded independent estimates of the amount of salvage provided by reperfusion with arterial blood. METHODS AND RESULTS Continuous electrocardiographic recordings were obtained from 14 study dogs undergoing a 90-minute period of coronary artery occlusion in which the severity of the ischemia during the occlusion was estimated at 10 and 45 minutes by microsphere injections. After 3 hours of reperfusion, the myocardium at risk and postmortem infarct size was measured. Myocardial salvage correlated inversely with both ST-segment elevation (r = -0.85; P < .0001), and QRS complex prolongation (r = -0.72; P = .003). When dogs were paired so that they had equal amounts of ST elevation but differed with respect to the presence of QRS prolongation, less myocardial salvage was found in those with QRS prolongation. The independent value of QRS prolongation was supported further by the observation that presence of QRS prolongation resulted in a loss of the highly significant correlation between ST elevation and salvage (r = -0.60; P = .2). CONCLUSIONS High magnitudes of ST elevation are correlated significantly with less myocardial salvage. Moreover, for a given magnitude of ST elevation, the presence of concurrent QRS prolongation is associated with even less myocardial salvage.
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Abstract
The ECG is an essential part of the initial evaluation of patients who have chest pain, especially in the immediate decision-making process in patients who have ST-elevation myocardial infarction. This article reviews and summarizes the current information that can be obtained from the admission ECG in patients who have ST-elevation acute myocardial infarction, with an emphasis on: (1) prediction of final infarct size, (2) estimation of prognosis, and (3) the correlations between various ECG patterns and the localization of the infarct and the underlying coronary anatomy.
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Affiliation(s)
- Shaul Atar
- Division of Cardiology, University of Texas Medical Branch, 5.106 John Sealy Annex, 301 University Boulevard, Galveston, TX 77555, USA
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Billgren T, Maynard C, Christian TF, Rahman MA, Saeed M, Hammill SC, Wagner GS, Birnbaum Y. Grade 3 ischemia on the admission electrocardiogram predicts rapid progression of necrosis over time and less myocardial salvage by primary angioplasty. J Electrocardiol 2005; 38:187-94. [PMID: 16003698 DOI: 10.1016/j.jelectrocard.2005.03.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Among patients with ST-elevation acute myocardial infarction, those with terminal QRS distortion (grade 3 ischemia) have higher mortality and larger infarct size (IS) than patients without QRS distortion (grade 2 ischemia). METHODS We assessed the relation of baseline electrocardiographic ischemia grades to area at risk (AR) and myocardial salvage [100 (AR-IS)/AR] in 79 patients who underwent primary angioplasty for first ST-elevation acute myocardial infarction and had technetium Tc 99m sestamibi single-photon emission computed tomography before angioplasty (AR) and at predischarge (IS). Patients were classified as having grade 2 ischemia (ST elevation without terminal QRS distortion in any of the leads, n = 48), grade 2.5 ischemia (ST elevation with terminal QRS distortion in 1 lead, n = 16), or grade 3 ischemia (ST elevation with terminal QRS distortion in >2 adjacent leads, n = 15). RESULTS Time to treatment was comparable among groups. AR was comparable among groups (38% +/- 20%, 33% +/- 23%, and 34% +/- 23%, respectively; P = .70). There were no differences among groups in residual myocardial perfusion (severity index 0.28 +/- 0.12, 0.29 +/- 0.16, and 0.30 +/- 0.15 in grades 2, 2.5, and 3 ischemia, respectively; P = .97). In contrast, there was a trend toward lower myocardial salvage (45% +/- 32%) in the grade 3 group than in the grade 2 (65% +/- 33%) and grade 2.5 (65% +/- 40%) groups ( P = .16). Salvage was dependent on time only in the grade 3 group. Spearman rank correlation coefficients between time to treatment and percentage salvage were 0.003 ( P = .99), -0.24 ( P = .38), and -0.63 ( P = .022) for grades 2, 2.5, and 3, respectively. CONCLUSIONS Patients with grade 3 ischemia have rapid progression of necrosis over time and less myocardial salvage. This admission pattern is a predictor of myocardial salvage by primary angioplasty.
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Affiliation(s)
- Therese Billgren
- Division of Cardiology, The University of Texas Medical Branch, Galveston, TX 77555, USA
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Gunnarsson G, Eriksson P, Dellborg M. Continuous ST-segment monitoring of patients with right bundle branch block and suspicion of acute myocardial Infarction. Ann Noninvasive Electrocardiol 2005; 10:161-8. [PMID: 15842428 PMCID: PMC6932291 DOI: 10.1111/j.1542-474x.2005.05613.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Patients with right bundle branch block comprise 5-9% of all patients with acute myocardial infarction. In spite of this, limited data exist on early diagnosis or the usefulness of continuous electrocardiographic monitoring in these patients. METHODS A prospective multicenter study with 14 Swedish coronary care units. Patients with right bundle branch block and suspicion of acute myocardial infarction with less than 6 hours symptom duration were included. All patients were monitored with continuous vectorcardiography for 12-24 hours. RESULTS Seventy-nine patients were included, 43% had acute myocardial infarction. Patients with acute myocardial infarction had significantly higher initial ST-vector magnitude values (P = 0.0014) compared to patients without acute myocardial infarction. Patients with acute myocardial infarction also showed gradual regression of ST-vector magnitude over time that was not seen for patients without acute myocardial infarction (P = 0.005). ST-vector magnitude measured at the J-point differentiated best between patients with and without acute myocardial infarction. A cutoff value of 125 microV for initial ST-vector magnitude resulted in 55% sensitivity and 87% specificity for the diagnosis of acute myocardial infarction. Over time, patients with acute myocardial infarction showed greater changes in QRS-vector difference compared to patients without acute myocardial infarction (P = 0.052). CONCLUSION Vectorcardiographic monitoring shows good diagnostic abilities for patients with right bundle branch block and clinical suspicion of acute myocardial infarction and could be useful for continuous monitoring of these patients.
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Affiliation(s)
- Gunnar Gunnarsson
- Department of Medicine, Akureyri Regional Hospital, Akureyri, Iceland.
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Dori G, Rosenthal A, Fishman S, Denekamp Y, S Lewis B, Bitterman H. Changes in the slope of the first major deflection of the ECG complex during acute coronary occlusion. Comput Biol Med 2005; 35:299-309. [PMID: 15749091 DOI: 10.1016/j.compbiomed.2004.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2003] [Accepted: 01/12/2004] [Indexed: 11/28/2022]
Abstract
To evaluate the effect of acute coronary occlusion (ACO) during percutaneous coronary intervention (PCI) on the slope of the first major deflection of the QRS complex (the initial QRS slope). Standard ECG signals of 18 patients (89 leads), undergoing PCI were recorded prior to and during ACO. The initial QRS slope was calculated in the baseline state and during ACO. Changes in the standard ECG were detected in 36 of 89 leads (40%). The initial QRS slope during ACO was significantly different from baseline in 74 of 89 leads (83%). The specificity of the change in the slope during ACO was low (29%).
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Affiliation(s)
- Guy Dori
- Department of Internal Medicine, The Lady Davis Carmel Medical Center, 7, Michal St., Haifa 34362, Israel.
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Poh KK, Chia BL, Tan HC, Yeo TC, Lim YT. Absence of ST elevation in ECG leads V7, V8, V9 in ischaemia of non-occlusive aetiologies. Int J Cardiol 2004; 97:389-92. [PMID: 15561323 DOI: 10.1016/j.ijcard.2003.10.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2003] [Revised: 08/28/2003] [Accepted: 10/12/2003] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Occlusion of the circumflex coronary artery may present with either ST elevation typical of inferior or lateral myocardial infarction, ST depression or a normal 12-lead electrocardiogram (ECG). In patients presenting with ST depression, concomitant ST elevation in the posterior leads V7, V8 and V9 is believed to reflect ST-elevation myocardial infarction of the posterior wall. However, to be confident of this diagnosis, it is necessary to know that posterior ST depression does not occur in acute subendocardial ischaemia. METHODS AND RESULTS We have prospectively recorded leads V7, V8 and V9 simultaneously with the standard 12-lead ECG in patients who underwent treadmill stress test. Group A consists of 35 patients who showed ischaemic praecordial ST depression in their 12-lead ECGs during treadmill stress test and subsequent angiographic documentation of significant coronary artery disease. Group B consists of 35 subjects who showed normal ECG findings during treadmill stress test. In none of the Group A or B patients was there ST elevation in leads V7, V8 or V9 either at rest or at peak exercise. ST depression was seen in 69% in V7, 31% in V8 and 11% in V9 in the Group A patients at peak exercise. CONCLUSION ST elevation in leads V7, V8 and V9 is uncommon in patients presenting with subendocardial ischaemia. Therefore, in patients presenting with acute chest pain and ST depression in the 12-lead ECG, concomitant posterior ST elevation may be a reliable indicator of ST elevation posterior MI. This is likely due to circumflex artery occlusion and may require thrombolytic therapy.
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Affiliation(s)
- Kian-Keong Poh
- Cardiac Department, National University Hospital, Singapore.
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Ortega-Carnicer J. Giant R wave, convex ST-segment elevation, and negative T wave during exercise treadmill test. J Electrocardiol 2004; 37:231-6. [PMID: 15286937 DOI: 10.1016/j.jelectrocard.2004.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The giant R wave syndrome is characterized by giant R wave accompanied by widening of the QRS complex, marked ST segment elevation, QRS axis deviation, and the formation of monophasic QRS-ST complex with obliteration of S wave in leads facing the ischemic zone. This report describes a 65-year-old-man with variant angina who had a transient giant R wave syndrome during an exercise treadmill test. Initially, at peak exercise, there was a convex ST segment elevation ending in a negative T wave in the same (inferior) leads which showed giant R waves. Later, in the recovery period and coinciding with an amelioration of myocardial ischemia, there was a less marked increase of R wave amplitude associated with concave ST segment elevation and positive T wave in the inferolateral leads. Subsequently, a ST segment depression in the inferolateral leads preceded the ECG normalization. The patient had also a concave ST segment elevation and positive T wave in inferolateral leads during a spontaneous episode of variant angina at rest. An emergency coronary arteriography showed a dominant right coronary artery with an 80% and a 75% diameter stenosis of the middle and distal segment, respectively; the other arteries and left ventriculogram were normal. The underlying mechanisms of the different shapes of ST segment elevation and T waveform in the setting of acute transmural myocardial ischemia are discussed.
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Billgren T, Birnbaum Y, Sgarbossa EB, Sejersten M, Hill NE, Engblom H, Maynard C, Pahlm O, Wagner GS. Refinement and interobserver agreement for the electrocardiographic Sclarovsky-Birnbaum Ischemia Grading System. J Electrocardiol 2004; 37:149-56. [PMID: 15286927 DOI: 10.1016/j.jelectrocard.2004.02.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Electrocardiogram-derived grades of ischemia at the time of patient presentation with acute myocardial infarction have proved useful in predicting the salvageability by reperfusion therapy, final infarct size, severity of left ventricular dysfunction, and short- and long-term prognosis. SUBJECTS AND METHODS The Sclarovsky-Birnbaum Ischemia Grading System based on the relation between the acute appearances of the T wave, the ST segment, and the QRS complex was considered as a means of enhanced ECG analysis in this group of patients. The evaluation of a training population (n = 46) resulted in refinement of the published description of the Sclarovsky-Birnbaum Ischemia Grading System, and a test population (n = 50) was utilized for investigating the interobserver agreement among 5 observers in determining the grade of ischemia. RESULTS The agreement among the observers applying the "refined" Sclarovsky-Birnbaum Ischemia Grading System was 0.89. Complete agreement was found for the ECGs of 80% of the patients, and the most common reason for disagreement was the application of the terminal T-negativity criterion. CONCLUSIONS The refined Sclarovsky-Birnbaum Ischemia Grading System can be performed manually with low interobserver variability. It has potential for support of the acute myocardial infarction triage decision as an electrocardiographic method for evaluating the level of ischemic protection at the time of either pre-hospital or emergency-department presentation.
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Affiliation(s)
- Therese Billgren
- Departmentof Cardiology, Duke Clinical Research Institute, Durham, NC, USA
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Dori G, Denekamp Y, Fishman S, Rosenthal A, Frajewicki V, Lewis BS, Bitterman H. Non-invasive computerised detection of acute coronary occlusion. Med Biol Eng Comput 2004; 42:294-302. [PMID: 15191073 DOI: 10.1007/bf02344703] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The goal of this study was to evaluate the role of a computerised, non-invasive ECG method for detecting acute coronary occlusion (ACO). Ninety-five standard ECG leads were recorded, before and during ACO, from 18 patients undergoing balloon angioplasty. ECG amplitude and derivative parameters were calculated for the ORS, ST and T components of the ECG signal, before and during ACO. Results were obtained for each lead. Sensitivity of the standard visual ECG analysis for detecting ACO was 48%, whereas the percentage of conventional ECG changes during baseline was 14%. For the best ECG parameter, the amplitude parameter of the ORS component, sensitivity was 82%, and the percentage of parameter changes during baseline was 20%. The sensitivity for detecting ACO with five of the six ECG parameters studied was greater than that of the standard visual analysis. Ischaemic changes were detected in 4.3 +/- 1.6 leads per patient using the amplitude parameter of the ORS component, whereas, with the standard visual analysis, 2.5 +/- 2.1 leads demonstrated such changes (p<0.001). Results were then summarized per patient. The standard visual ECG analysis detected ACO in 15 of 18 patients (83%), if at least one lead showed ischaemic changes. The computerised analysis detected ACO in all 18 patients using the same criterion. The sensitivity of the computerised method for detecting ACO in the clinical setting of angioplasty was greater than that of the standard visual analysis. It is suggested that the computerised method may be useful for detecting myocardial ischaemia in other clinical settings of acute myocardial ischaemia.
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Affiliation(s)
- G Dori
- Department of Internal Medicine, Carmel Medical Center, Haifa, Israel.
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Madias JE, Attari M. Exercise-triggered transient R-wave enhancement and ST-segment elevation in II, III, and aVF ECG leads: a testament to the “Plasticity” of the QRS complex during ischemia. J Electrocardiol 2004; 37:121-6. [PMID: 15127379 DOI: 10.1016/j.jelectrocard.2004.01.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We describe a patient with coronary artery disease who showed transiently augmented R-waves in his electrocardiogram (ECG) during the course of an exercise treadmill test (ETT), an ECG pattern occasionally associated with the hyperacute phase of myocardial infarction and variant angina. This change in the R-waves was noted in II, III, and aVF ECG leads and was associated with ST-segment elevation; both changed gradually and were normalized during the recovery period. Cardiac enzymes after ETT were negative, and arteriography revealed 3-vessel coronary artery disease, with a completely occluded right coronary artery. The ventriculogram showed very mild hypokinesis of the inferior left ventricular wall, while the global ejection fraction was 75%. These ECG changes, noted previously during ETT in precordial ECG leads, are herein reported to occur also in II, III, and aVF ECG leads. The generation of these ECG changes, which hinges upon a late unopposed depolarization occurring in the course and at the site of severe ischemic injury, constitutes a transient focal ventricular conduction abnormality.
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Affiliation(s)
- John E Madias
- Mount Sinai of Medicine of the New York University, New York, NY 11373, USA.
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Hedén B, Ripa R, Persson E, Song Q, Maynard C, Leibrandt P, Wall T, Christian TF, Hammill SC, Bell SS, Pahlm O, Wagner GS. A modified Anderson-Wilkins electrocardiographic acuteness score for anterior or inferior myocardial infarction. Am Heart J 2004; 146:797-803. [PMID: 14597927 DOI: 10.1016/s0002-8703(03)00404-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Optimal treatment of acute myocardial infarction (AMI) depends on the duration of the ischemia. The Anderson Wilkins (AW) electrocardiographic acuteness score has been shown to complement the historical timing in estimating the time interval from acute thrombotic coronary occlusion in patients presenting with chest pain and evolving myocardial infarction. The purposes of this study were to (1) compare the distributions of the previously developed AW acuteness score in a training population with either anterior or inferior AMI and (2) propose modifications to the formula to achieve distributions similar to the observed distributions of historical times from onset of pain. METHODS Two hundred three and 177 patients were included as training and testing population, respectively. All patients had an anterior or an inferior AMI and were without confounding factors on the electrocardiogram. RESULTS The training population had similar distributions of historical times from onset of pain, but differences in distributions of AW acuteness scores, between patients with anterior and inferior AMI (P <.0001). Eighty percent of the inferior AMI group had the highest possible AW acuteness score. Modification of a Q-wave criterion from > or =30 to > or =20 ms resulted in similar distributions in patients with anterior and inferior AMI both in the training and an independent testing population. CONCLUSIONS These results suggest that a modified AW acuteness score using a lower Q-wave duration criterion provides similar AMI timing information in patients with anterior and inferior locations. Clinical use of the AW acuteness score will only be practical if the calculation is automated.
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Affiliation(s)
- Bo Hedén
- Department of Clinical Physiology, Lund University, Lund, Sweden
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Birnbaum Y, Drew BJ. The electrocardiogram in ST elevation acute myocardial infarction: correlation with coronary anatomy and prognosis. Postgrad Med J 2003; 79:490-504. [PMID: 13679544 PMCID: PMC1742828 DOI: 10.1136/pmj.79.935.490] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The electrocardiogram is considered an essential part of the diagnosis and initial evaluation of patients with chest pain. This review summarises the information that can be obtained from the admission electrocardiogram in patients with ST elevation acute myocardial infarction, with emphasis on: (1) prediction of infarct size, (2) estimation of prognosis, and (3) the correlations between various electrocardiographic patterns and the localisation of the infarct and the underlying coronary anatomy.
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Affiliation(s)
- Y Birnbaum
- University of Texas Medical Branch, Galveston, Texas 77555-0553, USA.
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Efrati S, Cantor A, Goldfarb B, Ilia R. The predictive value of exercise QRS duration changes for post-PTCA coronary events. Ann Noninvasive Electrocardiol 2003; 8:60-7. [PMID: 12848815 PMCID: PMC6932111 DOI: 10.1046/j.1542-474x.2003.08110.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The sensitivity and predictive values of exercise ECG testing using ST-T criteria after percutaneous transluminal coronary angioplasty (PTCA) are low, precluding its routine use for screening for restenosis. The predictive value of QRS duration criteria during exercise testing (ET) ECG after PTCA for future coronary events has not been reported. The aim of the study was to compare QRS duration changes with ST-T criteria during ET, as a predictor of coronary events after PTCA. METHODS A prospective study of 206 consecutive patients who underwent ET at a mean of 34 +/- 14 days after their first PTCA, and were the followed for a mean of 23 +/- 9 months. Patients were divided by QRS duration into two groups-Q1: ischemic response (QRS duration prolongation of more than 3 ms relative to the resting duration), and Q2: normal response (QRS duration shortening or without change from resting duration). Patients were also divided by their ST-T response, S1: ischemic response, and S2: normal response. RESULTS During follow-up 52 patients (58%) experienced restenosis or MI, or underwent CABG-Q1: 44 (85%), Q2: 8(15%) (P < 0.0002), S1: 8 (15%), S2: 44 (85%), (P < 0.641), two patients died-Q1: 1 (1%) and Q2: 1 (1%). For QRS and ST-T, the relative risk of having at least one of the coronary events was 4.02 (CI 2.1-9.9) versus 1.13 (CI 0.8-2.9), respectively. The sensitivity for future coronary events was 85% and 52% and the specificity was 48% and 98% for the QRS and ST-T criteria, respectively. CONCLUSION QRS prolongation during peak ET ECG after PTCA is a more sensitive marker than ST-T criteria for detection of patients at risk for later coronary events.
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Affiliation(s)
- Shai Efrati
- Exercise Testing Unit, Cardiology Department, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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Dori G, Denekamp Y, Fishman S, Rosenthal A, Lewis BS, Bitterman H. Evaluation of the phase-plane ECG as a technique for detecting acute coronary occlusion. Int J Cardiol 2002; 84:161-70. [PMID: 12127368 DOI: 10.1016/s0167-5273(02)00141-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the phase plane (PP) ECG as a method for detecting acute coronary occlusion (ACO). BACKGROUND Balloon inflation in a coronary artery during PTCA produces acute myocardial ischemia. The sensitivity of the standard ECG for detecting ACO is approximately 50%, depending on the number of leads recorded. METHODS The standard ECG signals of 18 patients (91 leads), undergoing PTCA were sampled and converted to digital data, prior to, and during acute coronary occlusion. PPs were constructed by projecting the ECG signals and their first derivatives onto a two-dimensional plane. Standard ECG signals and PPs, prior to ACO, were compared to their respective recordings and PPs during ACO. RESULTS Using the standard ECG analysis, the acute occlusion was detected in 39 of 91 leads (43%), and in 15 of 18 patients (83%), whereas using the PP analysis it was detected in 82 of 91 leads (90%), and in all 18 patients (100%) (P<0.001, for leads). The median number of leads per patient demonstrating standard ECG changes was 2.0, whereas for the PP analysis it was 5.5 (P<0.001). The specificity of the PP method was 83.5%. CONCLUSIONS The sensitivity of the PP method for detecting ACO during PTCA was superior to that of the standard ECG analysis. A smaller lead system is required to detect changes of ACO, during PTCA, when the PP method is used. The PP method is simple, low-priced, and may serve to detect acute myocardial ischemia in a number of clinical settings.
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Affiliation(s)
- Guy Dori
- Department of Internal Medicine A, Carmel Medical Center, 7 Michal St., 34362 Haifa, Israel.
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